Getting More Nodes of No Benefit in Colon Cancer Surgery

Action Points

Explain to patients that the study showed no advantages to examining 12 or more lymph nodes in patients with colorectal cancer.

HOUSTON, July 20 -- Retrieving more lymph nodes during colorectal cancer resection does not improve detection of stage III disease or identify more patients with positive nodes, data from a large case series showed.

In fact, the proportion of patients with stage III diagnoses actually tended to decline as the number of lymph nodes retrieved increased, Tina Hieken, MD, of Rush Medical College in Chicago, and colleagues reported in the July issue of Archives of Surgery.

The distribution of N1 and N2 disease also did not change significantly with increased lymph-node retrieval.

"Our data suggest that harvest of at least 12 lymph nodes as a quality or performance measure appears unfounded," the authors concluded.

In 1990 participants in the World Congress of Gastroenterology introduced the concept that identification of at least 12 lymph nodes as the minimum acceptable number for patients undergoing resection of colorectal cancer.

Subsequently, other organizations adopted the benchmark, including the American College of Surgeons, the American Society of Clinical Oncology, and several insurers.

However, recent population-based studies have suggested that in a majority of patients with operable colorectal cancer, doctors do not retrieve at least 12 lymph nodes, the authors said.

Studies evaluating the benefits of increased lymph-node retrieval have yielded mixed results, as some studies showed improved detection of metastatic disease and others did not.

Most studies have focused on surgeon-related variables influencing lymph-node retrieval. In a previous study, the authors found that the variability extended beyond surgeon-specific factors and included the individual pathologist, patient age, comorbid illness, and tumor stage and location.

The current study focused on results of a multidisciplinary approach to increase lymph node counts and to determine the effect on diagnosis of stage III disease or the number of positive nodes per case.

The initiative included a program aimed at increasing institutional awareness of the issues.

Additionally, institutional pathologists modified their approach to lymph node assessment. Pathologists used a formalin-based fat-clearing solution to improve lymph node yield. If fewer than 12 nodes were identified, the blocks were routinely reevaluated.

The study included 701 consecutive colorectal cancer patients, 553 of whom had surgery before the initiative and 148 patients who had surgery after the program began.

The mean lymph-node count increased from 12.8 before the initiative to 17.3 afterward (P<0.001).

The number of resections with at least 12 nodes retrieved increased from 53% to 71.6% (P<0.001).

The proportion of patients with stage III disease tended to decrease from 36.9% prior to the institutional initiative to 32.4% for the later patient group (P=0.31).

In an invited discussion that followed the article, University of Louisville surgeon Charles Scoggins, MD, said the study demonstrated a phenomenon common to many hospitals.

"When I am not satisfied with the number of nodes reported, I simply call the pathologist and order more nodes," he said. "Magically, they are able to find more.

"This point serves as the main stratification variable in this paper: they 'ordered' more nodes and the pathologists responded. This has not, however, led to stage migration or the distribution of N1 and N2 disease. This is simply an observation and appears not to have affected patient care in any meaningful way.

"In essence, no more patients are eligible for adjuvant chemotherapy because of this change in policy at their hospital."

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